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Resources For

Healthcare Carriers

Overview

Note

We are looking for new Community Rated HMOs.

The U.S. Office of Personnel Management (OPM), administrator of the Federal Employees Health Benefits (FEHB) Program, would like to expand nationwide the number of health maintenance organizations (HMO) available in the Program. With the introduction of the medical loss ratio (MLR) regulations, OPM is hoping that health insurance carriers will be interested in either applying or re-applying for participation under this new pricing method, which replaces the similarly-sized subscriber groups (SSSG) method.

Thank you for visiting the Federal Employees Health Benefits (FEHB) Program's carrier application and information web pages. We created the following pages for health insurance companies interested in participating as a health carrier in our Program. There are three screens:

This first screen provides information on the types of health insurers that the Office of Personnel Management (OPM) can approve for participation in the FEHB program.

The second screen will ask you to enter specific identifying data such as your name and professional title, your health insurance company and its address. Completing this screen does not constitute submission of your application. We use this information to follow-up with you concerning your interest and your progress in completing the application.

The third screen will automatically appear once you complete the data we requested on the second screen. On this screen you will find links to the downloadable application files. To apply for participation in the FEHB Program, you must complete all files. OPM must receive your application by January 31.

What types of health insurers qualify for participation in the FEHB Program?

We will consider applications only from comprehensive, prepaid medical plans. The FEHB Program contracts only with health benefits carriers that offer a complete line of medical services, such as doctor's office visits, hospitalization, emergency care, prescription drug coverage, and treatment of mental conditions and substance abuse. We do not have the authority to contract with companies that offer limited services, such as dental and/or vision plans, prescription drug plans, supplemental insurance and disability insurance. We can not consider applications from fee-for-service carriers.

We especially invite qualified applicants from the states that the Department of Health and Human Services (HHS) has determined to be medically underserved -- Alabama, Arizona, Idaho, Illinois, Louisiana, Mississippi, Missouri, Montana, New Mexico, North Dakota, Oklahoma, South Carolina, South Dakota, and Wyoming.

We invite you to apply if you believe you qualify to participate in the FEHB Program. Please go to the next screen. If you have a question, please call our HMO contracts office at 202-606-0755 or 202-606-0737 and ask to speak with a contract specialist.

Carrier Letters

Carrier Letters Archive

You have reached a collection of archived material.

The content available is no longer being updated and as a result you may encounter hyperlinks which no longer function. You should also bear in mind that this content may contain text and references which are no longer applicable as a result of changes in law, regulation and/or administration.

Performance Assessment

The Office of Personnel Management’s (OPM) goal is to improve the health of the populations we serve, ensure the delivery of high quality consumer focused health care, and provide Federal employees and retirees with affordable insurance benefits. We evaluate FEHB Carriers on key parameters of clinical quality, customer service, resource use, and contract oversight.

Many aspects of our performance assessment framework rely on measures from the Healthcare Effectiveness Data and Information Set (HEDIS), and Consumer Assessment of Healthcare Providers and Systems (CAHPS). Scoring measures against national benchmarks helps OPM recognize top performing health insurance carriers in the program, inform enrollee choice, and link objective performance to profit factors. The first year of data collection using OPM’s measures hierarchy and value-based purchasing methodology was in 2016.

We encourage FEHB carriers to become active in the Health Care Payment Learning and Action Network, which the Department of Health and Human Services established as a means for promoting proven value-based payment models among commercial carriers. Carriers interested in joining the FEHB Program should carefully review materials listed under the subject areas on this page.

Below are links to more FEHB Plan Performance Assessment Information:

FEHB Carrier Letters – Plan Performance Assessment

The table below is a list of the FEHB Carrier Letters related to the Plan Performance Assessment.

The purpose of this Carrier Letter is to simplify administration of the FEHB Plan Performance Assessment (PPA) by consolidating methodology guidance. The PPA was announced in 2014. Carrier payment based on PPA scoring began in 2016. This letter compiles all current guidance regarding the methodology. Carriers must reference the annual PPA Procedure Manual for operational instructions and specific measures that must be reported to OPM.

The purpose of this Carrier Letter is to announce the Clinical Quality, Customer Service, and Resource Use (QCR) measures to be utilized in the 2019 Plan Performance Assessment. A list of the 2019 QCR Measure Set is included in Attachment 1.

This carrier letter details policies and procedures pertaining to the Federal Employees Health Benefits (FEHB) Plan Performance Assessment Best Practices Workgroup. In this notice, it is hereafter referred as the "Best Practices Workgroup" or the "workgroup."

Announced a proposed update to the Federal Employees Health Benefits (FEHB) Program Plan Performance Assessment for Community Rated Carriers. Beginning with the 2017 performance assessment period and for future rating periods a Community-Rated Adjustment (CRA) would be applied to the overall performance score (OPS) of community-rated carriers in the FEHB Program to incentivize high performance.

Released the methodology for the FEHB Plan Performance Assessment Improvement Increment that OPM will implement as part of the Fall 2017 Clinical Quality, Customer Service, and Resource Use (QCR) calculation.

Outlines the process for collection and submission of measures to the OPM for the Federal Employees Health Benefits (FEHB) Plan Performance Assessment This combines HEDIS and CAHPS reporting info, and includes the data correction procedures.

Provides the full set of domains and components for the four proposed performance areas, including updates to the previously published measures and details of the Contract Oversight performance area, for 2016.